anaphylaxis
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Anaphylaxis
Johannes Ring Klinik und Poliklinik für Dermatologie und Allergologie am
BiedersteinTechnische Universität München
Munich, Bavaria, GermanyGA2LEN Center of Excellence EU frame program
Christine Kühne Center for Allergy Research and Education (CK-CARE)
XXII World Allergy Congress WAC 4 – 4 december 2011, Cancun Mexico
Anaphylaxis: definition by the World Allergy Organization
Johansson SGO et al. Revised nomenclature for allergy for global use: Report of the Nomenclature Review Committee of the World Allergy Organization, J Allergy Clin Immunol. 2004;113:832-6.
„Anaphylaxis is an (acute) severe, life-threatening
generalized or systemic hypersensitivity reaction“
(regardless of mechanism)
Increase in Incidence of Anaphylaxis
Liew WK. Anaphylaxis fatalities and admissions in Australia. J Allergy Clin Immunol 2009;123:434-42
Anaphylactic Reaction after Infusion of Dextran 60
Day 1, Unit 2a
Severity grading of anaphylactic reactions according to Ring and Meßmer (Lancet, 1977)
Grade
Symptoms observed
Skin Gastro-intestinal
Respiratory Cardio-vascular
I
Itch Flush Urticaria Angioedema
- - -
II „
(not obligatory)
Nausea Cramps
Rhinorrhoea Hoarseness Dyspnoea
Tachycardia(>20/min)RR changes(>20mmHg syst)Arrhythmia
III
„(not
obligatory) Vomitus Defecation
Laryngeal edema Bronchospasm Cyanosis
Shock
IV
„(not
obligatory)
„ Respiratory arrest
Cardiac arrest
Activators
Allergen
Auto-Ab
(IgE,FcRI)
Anaphylatoxin
Tryptase
Basic agents(Neuropeptides,
48/80,MBP)
Adenosin
Chemokines
Stem cell factor(c-kit-Ligand)
Microbial
Peptides
Mediators
Histamine
Proteoglykanes
Proteases
Other Enzymes
Cytokines
Lipid mediators
Mast Cells
I. Weichenmeier, H. Behrendt
33 jährige Patientin mit Mastozytose (ISM) seit 4 JahrenBronchialasthmaKeine frühere Allergie oder AnaphylaxieBasale Tryptase 57µg/l
Patientin wurde von Wespe in den Nacken gestochenPatientin hatte kein Notfall-Set dabeiTachykardie, Kollaps, Bewußtseinsverlust innerhalb weniger MinutenReanimation anfangs erfolgreich, aberspäter auf Intensivstation Tod durch hypoxischen Hirnschaden
Frage einer evtl. „prophylaktischen“ ASIT (Immuntherapie)
mast cell
mediator substanceseg histamine
nettle rash
dyspnoea
diarrhea, vomiting
shock
Day 1, Unit 2a
Mechanisms of anaphylaxis
Triggers of Anaphylaxis
Modif. After Hompes S et al 2009
Trigger Adults Children
Foods 16 54
Insects 55 16
Drugs 21 8
Elicitors or letal anaphylaxis
Pumphrey. Clin Exp Allergy 2000; 30:1144
Insect venoms
Foods
Drugs
Circumstances of fatal food anaphylaxisCircumstances of fatal food anaphylaxis
• Most of patients are aware of food allergy
• Mostly young asthmatics
• Several mild reactions in previous history
• Difficulties in complete avoidance
• Reactions occur mostly not at home, but in school, kindergarden , bars, restaurants, „Take-Away“, Caterer
Summation anaphylaxisSummation anaphylaxis
Nahrungsmittel
Infekte
Streß
Klima
Sport
Arzneimittel
Alkohol
Guidelines in Anaphylaxis
• 1994 Konsensuskonferenz DGAI Tryba et al Allergo-J
• 2005 Update parameter AAAAI Lieberman et al JACI
• 2006 2nd symposium NIH / FAN Sampson et al JACI
• 2007 Leitlinie Akutmaßnahmen bei Anaphylaxie Ring et al (DGAKI)Allergo-J
• 2007 Anaphylaxis in childhood (EAACI) Muraro et al Allergy
• 2008 Epinephrine – drug of choice (WAO) Kemp et al WAO Journal
• 2011 Development of Global Guidelines (WAO) Simons et al JACI
Development of „Anaphylaxis School“ by working group AGATE (AG Anaphylaxis Training and Education)
• Johannes Ring, Knut Brockow, Claudia Kugler, Martine Grosber Verena Thiebes (München TUM)
• Kirsten Beyer, Norbert Gebert (Berlin) Margitta Worm (Berlin)
• Tilo Biedermann, A Fischer (Tübingen)• Alexander Dorsch (Hohenkammer)• Ricarda Eben, B Przybilla (München
LMU)• Frank Friedrichs (Aachen)• Uwe Gieler, S Schallmayer (Gießen) • Thilo Jakob (Freiburg)• Lars Lange (Bonn)• Oliver Pfaar, Ludger Klimek (Wiesbaden)• Imke Reese (München)• Ernst Rietschel (Köln)• Sabine Schnadt (daab)• Rüdiger Szczepanski (Osnabrück)
Skin: Itch, reddening, swelling, nettle rash
Gastrointestinal tract: Itchy palate, nausea, vomiting, abdominal cramps, diarrhea
Respiratory tract: Cold, narrow throat, stridor, cough, dyspnoea
Cardiovascular: Vertigo, disorientation, tachycardiahypotension, collapse, unconsciousness shock
Symptoms of anaphylaxis
Day 1, Unit 2a
AGATE
Interdisciplinary Group:
• Dermatologist• Emergency Physician• ENT• Pneumologist• Nutritionist • Pediatrician• Psychologist• Patient organisation
Struktured educational programs („Schools“) in allergy
• Asthma Arbeitsgemeinschaft Asthma-Schulung (AGAS)
• Neurodermitis Arbeitsgemeinschaft Neurodermitis-Schulung (AGNES)
• Anaphylaxie Arbeitsgemeinschaft Anaphylaxie – Training und Edukation (AGATE)
General measures
Adrenaline
Volume
Basics of Treatment of AnaphylaxisBasics of Treatment of Anaphylaxis
Antihistamine Glucocorticoids
„„Emergency Set“ for self-medicationEmergency Set“ for self-medication
• Adrenaline, Antihistamine, Cortisone• Application galenics for easy swallowing • Adrenaline as Autoinjector
+ +
Objectives of AGATE
• Basic knowledge anaphylaxis (symptoms, medication)
• Coping with anaphylactic reactions
• Practical training in use of self medication
• Avoiding triggers
• Coping with fear
• Exchange of experiences with other patients
Who is educated?
• Patients and relatives
• Patients to whom an epinephrine autoinjector was prescribed (anaphylaxis, adults with mastocytosis)
• Train the Trainer Seminars: Physicians (Allergists), Psychologists, Nutritionists
Structure of Programmme
• Outpatient education
• 2 Meetings with 4 units of 45 minutes
• Interdisciplinary approach
• Standardised programme with manual
• Groups of 6 adults or 12 parents of 6 children
• Opportunities and limits of educational programs (1 TU)
• Basics of organization and management of patient education schools (3 TU)
• Psychosocial aspects (6 TU)
• Pedagogic basics (8 TU)
• Medical aspects of anaphylaxis (10 TU)
Qualification for „Anaphylaxis Trainer“according to the AGATE curriculum: Contents
TU =teaching unit á 45 minutes
• Methodic/didactic opportunities for all age groups
• Adequate didactic tools and gadgets for working with children, parents and adults or kindergarden personel
• Group dynamics• Group structuring, processes, intervention
methods• Relaxation and body perception• Role performance games illustrating initiation
and solution of problems under everyday conditions
Qualification for „Anaphylaxis Trainer“according to the AGATE curriculum:
Pedagogic content
• Basics of anaphylaxis– Symptoms, early warning signs – Triggers– Diagnosis and differential diagnoses – Individual risk and influencing factors
• Survey of treatment options– Trigger avoidance– Allergen-specific immunotherapy (ASIT)– Outlook to future approaches
• Practical management in case of emergency– Emergency set: medications– Application of emergency medication– Adrenaline autoinjector training
Anaphylaxis School: Contents 1st Day
Day 1, Unit 1 b
• What to do in case of emergency? (repetition)– Anaphylaxis
– Recognition– Remembering – Counteracting– Taking serious
• Elicitor-specific modules for:– Foods - Drugs– Insect venoms - Latex
• Everyday survival strategies • Anaphylaxis and social environment
Day 2, Unit 1b
Anaphylaxis School: Contents 2nd Day
Qualification for „Anaphylaxis Trainer“according to the AGATE curriculum
• Medical: Allergist or equivalent experience
• Psychological: Psychology, Psychosomatic medicine, Psychotherapy, pedagogics plus > 1 year experience in behavioural therapy with chronic diseases
• Nutrition: ecotrophology, dietary assistance with special experience in food allergy (membership in WG)
• Nurse/children‘s nurse: optional
• Hospitation (observer) in anaphylaxis school
• Train-the-Trainer seminar
• Supervision
• Certificate
Qualification for „Anaphylaxis Trainer“according to the AGATE curriculum: Program
Prevention
avoid triggers
knowalternatives
immunotherapy for Insect venom allergy
take emergency drugs always along
train application ofemergency drugs
inform social environment
individualemergency plan
knowsymptoms
remember
Day 1, Unit 3
Conclusions
• Anaphylaxis is not rare• Main elicitors are drugs, insects and foods• Adrenaline is the main drug in acute treatment• It is important to find causal elicitor by allergy
diagnostics• If possible, allergen-specific immunotherapy• Research regarding „summation“ factors is
necessary• Strict avoidance of elicitor is best prevention• The „anaphylaxis school“ program is helpful in
acute management and avoidance of elicitors thus facilitating patient‘s life
Thanks to:K. Brockow
C. Kugler
U. Darsow
M. Grosber
V. Thiebes
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